The diagnostic yield of open-access endoscopy of the upper gastrointestinal tract in the Netherlands

Abstract

Background and study aims Since the introduction of open-access esophago-gastroduodenoscopy (OAE) there is an increase in the total number of performed OAEs whilst the frequency of clinical relevant findings has decreased. The aim of this study was to assess the appropriate use and the diagnostic yield of OAE in the Netherlands and to determine which patient variables are able to predict a malignant finding.

Patients and methods A retrospective chart review of all referrals for diagnostic OAE between October 2012 and October 2016 at the Northwest Clinics was performed. The indications were recorded from the referral letter and were classified as “appropriate” or “inappropriate” according to the NHG guideline. Logistic regression was used to detect significant predictive variables for a malignancy.

Results A total of 2006 patients were included, of whom 59.6 % had an ‘appropriate’ referral indication. The diagnostic yield of finding a clinical relevant finding was significantly higher for OAEs with an “appropriate” referral indication. Independent risk factors for malignancy were alarm symptoms, age and male gender with a combined AUC of 0.868.

Conclusions Only 3.8 % of the malignancies would be missed by strict adherence to the guideline. This indicates that the open-access system in the Netherlands works well. Further improvement of the system can be achieved by only accepting appropriate indications for OAE and by treating patients under the age of 40 without OAE. We showed that a risk-prediction model based on the variables age, alarm symptoms and male gender is a good predictor of malignant finding.

• References

• 1 Van Kerkhoven LAS, Van Rijswijck SJ, Van Rossum LGM. et al. Open-access upper gastrointestinal endoscopy a decade after the introduction of proton pump inhibitors and Helicobacter pylori eradication: A shift in endoscopic findings. Digestion 2007; 75: 227-31
• 2 Talley NJ, Vakil N, Delaney B. et al. Management issues in dyspepsia: Current consensus and controversies. Scand J Gastroenterol 2004; 39: 913-918
• 3 Buri L, Bersani G, Hassan C. et al. How to predict a high rate of inappropriateness for upper endoscopy in an endoscopic centre?. Dig Liver Dis 2010; 42: 624-628
• 4 Chan YM, Goh KL. Appropriateness and diagnostic yield of EGD: A prospective study in a large Asian hospital. Gastrointest Endosc 2004; 59: 517-524
• 5 Numans ME, De Wit NJ, Dirven JAM. et al. NHG-Standaard Maagklachten (derde herziening). 2013 https://www.nhg.org/standaarden/volledig/nhg-standaard-maagklachten-derde-herziening
• 6 Broe M, Barry M, Patchett S. et al. Evaluating the clinical efficacy and cost effectiveness of direct access endoscopy. Surgeon 2013; 11: 304-308
• 7 Boulton-Jones JR, Follows MC, Mahmoud AA. Open-access endoscopy: Are age-based guidelines justified? An audit of experience of 1000 open-access endoscopies at a district general hospital. Endoscopy 2003; 35: 68-73
• 8 Keren D, Rainis T, Stermer E. et al. A nine-year audit of open-access upper gastrointestinal endoscopic procedures: Results and experience of a single centre. Can J Gastroenterol 2011; 25: 83-88
• 9 Mangualde J, Cremers MI, Vieira AM. et al. Appropriateness of outpatient gastrointestinal endoscopy in a non-academic hospital. World J Gastrointest Endosc 2011; 3: 195-200
• 10 Manes G, Balzano A, Marone P. et al. Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system: A prospective observational study based on the Maastricht guidelines. Aliment Pharmacol Ther 2002; 16: 105-110
• 11 Salo M, Collin P, Kyronpalo S. et al. Age, symptoms and upper gastrointestinal malignancy in primary care endoscopy. Scand J Gastroenterol 2008; 43: 122-127
• 12 Numans ME, van der Graaf Y, De Wit NJ. et al. How useful is selection based on alarm symptoms in requesting gastroscopy? An evaluation of diagnostic determinants for gastro-oesophageal malignancy. Scand J Gastroenterol 2001; 36: 437-443
• 13 Vakil N, Moayyedi P, Fennerty MB. et al. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology 2006; 131: 390-401
• 14 Integraal kanker centrum Nederland. www.cijfersoverkanker.nl
• 15 Di Giulio E, Hassan C, Marmo R. et al. Appropriateness of the indication for upper endoscopy: a meta-analysis. Dig Liver Dis 2010; 42: 122-126
• 16 Hassan C, Bersani G, Buri L. et al. Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy. Gastrointest Endosc 2007; 65: 767-774
• 17 Aljebreen AM, Alswat K, Almadi MA. Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system. Saudi J Gastroenterol 2013; 19: 219-222
• 18 Trevisani L, Sartori S, Gilli G. et al. Appropriateness of upper gastrointestinal endoscopy: A hospital-based study. Dig Dis Sci 2001; 46: 2695-2699
• 19 Rossi A, Bersani G, Ricci G. et al. ASGE guidelines for the appropriate use of upper endoscopy: association with endoscopic findings. Gastrointest Endosc 2002; 56: 714-719
• 20 Shekelle PG. Are appropriateness criteria ready for use in clinical practice?. N Engl J Med 2001; 344: 677-678
• 21 Group CC. Gastric cancer and Helicobacter pylori : a combined analysis of 12 case control studies nested within prospective cohorts. Gut 2001; 49: 347-353
• 22 Islami F, Kamangar F. Helicobacter pylori and Esophageal Cancer Risk – A Meta- Analysis. Cancer Prev Res 2008; 1: 329-338
• 23 Fransen GAJ, Janssen MJR, Muris JWM. et al. Meta-analysis: The diagnostic value of alarm symptoms for upper gastrointestinal malignancy. Aliment Pharmacol Ther 2004; 20: 1045-1052
• 24 Voutilainen M, Mäntynen T, Mauranen K. et al. Is it possible to reduce endoscopy workload using age, alarm symptoms and H. pylori as predictors of peptic ulcer and oesophagogastric cancers?. Dig Liver Dis 2005; 37: 526-532
• 25 Khademi H, Radmard AR, Malekzadeh F. et al. Diagnostic accuracy of age and alarm symptoms for upper GI malignancy in patients with dyspepsia in a GI clinic: A 7-year cross-sectional study. PLoS One 2012; 7: 1-10
• 26 Williams B, Luckas M, Ellingham JH. Do young patients with dyspepsia need investigation?. Lancet (London, England) 1988; 8624: 1349-1351
• 27 Canga C, Vakil N. Upper GI malignancy, uncomplicated dyspepsia, and the age threshold for early endoscopy. Am J Gastroenterol 2002; 97: 600-603
• 28 Gillen D, McColl KEL. Does concern about missing malignancy justify endoscopy in uncomplicated dyspepsia in patients aged less than 55?. Am J Gastroenterol 1999; 94: 75-79
• 29 Lassen AT, Pedersen FM, Bytzer P. Helicobacter pylori test-and-eradicate versus prompt endoscopy for managment of dyspeptic patients: A randomised trial. Lancet (London, England) 2000; 356: 455-460
• 30 Heaney A, Collins JSA, Watson RG. A prospective randomised trial of a ‘test and treat’ policy versus endoscopy based management in young Helicobacter pylori positive patients with ulcer-like dyspepsia, referred to a hospital clinic. Gut 1999; 45: 186-190
• 31 Marmo R, Rotondano G, Piscopo R. et al. Combination of age and sex improves the ability to predict upper gastrointestinal malignancy in patients with uncomplicated dyspepsia: A prospective multicentre database study. Am J Gastroenterol 2005; 100: 784-791
• 32 Van Kerkhoven LAS, Van Rijswijck SJ, Van Rossum LGM. et al. Is there any association between referral inidcations for open-access upper gastrointestinal endoscopy and endoscopic findings?. Endoscopy 2007; 39: 502-506
• 33 Blustein PK, Beck PL, Meddings JB. The ultility of endoscopy in the management of patients with gastroesophageal reflux symptoms. Am J Gastroenterol 1998; 93: 2508-2512
• 34 Naji SA, Brunt PW, Hagen S. et al. Improving the selection of patients for upper gastrointestinal endoscopy. Gut 1993; 34: 187-191
• 35 Rabeneck L, Wristers K, Souchek J. et al. Impact of upper endoscopy on satisfaction in patients with previously uninvestigated dyspepsia. Gastrointest Endosc 2003; 57: 295-299
• 36 Wiklund I, Glise H, Jerndal P. et al. Does endoscopy have a positive impact on quality of life in dyspepsia?. Gastrointest Endosc 1998; 47: 449-454
• 37 Bytzer P, Hansen JM, Schaffalitzky de Muckadell OB. Emperical H2-blocker therapy or prompt endoscopy in management of dyspepsia. Lancet (London, England) 1994; 343: 811-816